8. Hypertension

Question 1

Before taking a patients blood pressure, what should you make sure?

Answer 1

• They don’t have an AV fistula or any arm that they have been told not to use
• In the last 15 minutes, they have not drunk alcohol, smoked or had a caffeinated drink

Question 2

What are the types of hypertension? Which is most common?

Answer 2

Primary hypertension / essential hypertension is when it has developed on its own without a known cause. It accounts for 95% of hypertension.

Secondary hypertension is when hypertension has developed because of a known cause (ie. secondary to a condition)

Question 3

What are the main causes of secondary hypertension?

Answer 3

Remember it using ROPE

R- Renal Disease (ie. renal artery stenosis)
O - Obesity
P - Pregnancy-Induced hypertension / pre-eclampsia
E - Endocrine (most endocrine conditions cause hypertension, but especially consider hyperaldosteronism)

Question 4

When should you perform specialist investigations on someone with hypertension?

Answer 4

• If they are under 40 years of age

- If they have a potential secondary cause

Question 5

What are some risk factors for essential hypertension?

Answer 5

STRONG

• Obesity
• Aerobic exercise <3 times/week
• Moderate/high alcohol intake
• Metabolic syndrome
• Diabetes mellitus
• Black ancestry
• Age >60 years
• Family history of hypertension or coronary artery disease
• Sleep apnoea

WEAK

• Sodium intake >1.5 g/day
• Low fruit and vegetable intake
• Dyslipidemia

Question 6

What is Dyslipidemia?

Answer 6

An abnormal amount of lipids (ie. triglycerides, cholesterol and/or fat phospholipids) in the blood

Question 7

Which arm should you measure blood pressure on?

Answer 7

Ideally you should measure on both arms

Question 8

What happens if there is a difference in blood pressure between arms?

Answer 8

If the difference is below 15 mmHg, take an average.

If its more than 15mmHg, repeat the measurements. If it remains, then use the arm with the higher reading

Question 9

When can automated blood pressure devices become unreliable? How do you predict this?

Answer 9

When the patient has pulse irregularity (for ex. due to atrial fibrilation) then it can be unreliable.

Before putting the automated device on, palpate the radial or brachial pulse to assess for regularity.

Question 10

How should you measure blood pressure in someone with symptoms of postural hypertension?

Answer 10

1. Measure blood pressure whilst sat down
2. Get them to stand up for atleast a minute
3. Measure blood pressure whilst they are stood up
4. If systolic BP falls by more than 20mmHg, measure subsequent BP whilst they are standing

Question 11

How do you record a ‘clinic BP’?

Answer 11

1. Record BP
2. If BP is greater than 140/90, take a second recording
3. If second reading is substantially different, then do a 3rd measurement
4. Record the lower of the last 2 measurements as the clinically blood pressure

Question 12

What do you do next if you diagnose someone with a clinical blood pressure of 141/90

Answer 12

As this is between 140/90 and 180/120, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. if ABPM is unsuitable, then offer home blood pressure monitoring (HBPM)

Question 13

How is ambulatory blood pressure monitoring set up so that it can diagnose hypertension?

Answer 13

It records the patients blood pressure atleast twice per hour during the patients usual waking hours (eg. from 8am to 10pm). The average value of all these results is used to diagnose hypertension

Question 14

How is home blood pressure monitoring set up so that it can diagnose hypertension?

Answer 14

1. For each BP reading, it is recorded twice, atleast 1 min apart. if the results are significantly different, do a 3rd measurement.
2. Record it in the morning (6am-12pm) and afternoon (6pm-12am) each day
3. This should be repeated for atleast 4 days, but ideally 7
4. ignoring the first days results, average the rest of them to find an average blood pressure value

Question 15

What should you do whilst you wait for either ABPM or HBPM to confirm a diagnosis of hypertension?

Answer 15

Carry out investigations for target organ failure

Question 16

What investigations can you do to check for target organ damage?

Answer 16

• U&E
• GFR
• HbA1C
• Lipid Profile
• Urine albumin:creatinine ratio
• ECG
• Form a Qrisk3 score

Question 17

If someone has a blood pressure of greater than 180/120, what factor decides how to manage this patient?

Answer 17

Whether or not there are signs and symptoms of end-organ failure

Question 18

When should you send someone with hypertension for a same-day specialist assessment?

Answer 18

When they have a Bp over 180/120 and 1 or 2 of;

• Signs of retinal haemorrhage and papilloedema
• Life-threatening symptoms, such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury.

Question 19

How should you manage a patient with a BP of greater than 180/120, but whose not reporting any symptoms or signs?

Answer 19

• Carry out investigations for target organ damage as soon as possible
• If target organ damage is found, consider starting them on anti-hypertensives immediately without waiting for the results of ABPM or HBPM

Question 20

How should you manage a patient with a BP of greater than 180/120, but whose not got any signs of target organ failure?

Answer 20

Repeat blood pressure measurement within 7 days

Question 21

What is required to diagnose hypertension?

Answer 21

Clinic blood pressure of 140/90 mmHg or higher PLUS ABPM / HBPM average of 135/85 or higher

Question 22

If there is a difference of greter than 20/10 between clinic BP and home BP, what should you be suspecting?

Answer 22

White coat syndrome`

Question 23

What is masked hypertension and when would you suspect it?

Answer 23

When clinic BP is normal but home BP are higher

Question 24

How often should you get your blood pressure measured?

Answer 24

Atleast every 5 years, and consider doing it more frequently if the persons clinic blood pressure is close to 140/90 mmHg

Question 25

What is a Qrisk3 score?

Answer 25

The Qrisk3 algorithm calculates a person's risk of developing a heart attack or stroke over the next 10 years. It can be calculated by putting their risk factors into a online calculator.

Question 26

What are the stages of hypertension?

Answer 26

Stage 1 - 135/85 to 149/94 Stage 2 - 150/95 to 179/119 Stage 3 - 180/20 and above

Question 27

What are the 2 types of hypertensive crisis?

Answer 27

- Hypertension Urgency | - Hypertension Emergency

Question 28

What is a hypertension urgency crisis?

Answer 28

This is when systolic BP is greeater than 180 mmHg, or diastolic BP is greater than 110 mmHg. There is no acute damage to any of the target organs

Question 29

What symptoms would someone in a hypertensive urgency report?

Answer 29

They may report any of the following symptoms; - Headache - Shortness of breath - Nose bleed (epistaxis) - Severe anxiety

Question 30

How is a hypertensive urgency managed?

Answer 30

Oral anti-hypertensive medication Typically done in an outpatient or same-day observational setting

Question 31

What is a hypertensive emergency crisis? What can it also be called?

Answer 31

This is when blood pressure is so high that it has reached levels that damage target organs. Sometimes this is also referred to as malignant hypertension.

Question 32

How high is BP in a hypertensive emergency?

Answer 32

Systolic blood pressure can be over 180 mmHg, and diastolic blood pressure can be greater than 120 mmHg. However, a hypertension emergency can also occur at lower blood pressures, in patients whose bodies aren't as used to high blood pressures.

Question 33

What symptoms would someone in a hypertensive emergency report?

Answer 33

- Chest pain - Shortness of breath - Back pain - Numbness/weakness - Vision change - Difficulty speaking

Question 34

How can a hypertensive emergency result in encephalopathy?

Answer 34

Due to high blood pressure, blood is forced out of cerebral capillaries, which is both toxic to the neural tissue, and also causes increased intracranial pressure, which if untreated it leads to permanent brain dysfunction

Question 35

How and where is a hypertensive emergency treated?

Answer 35

As its complications are severe, treatment needs to be speedy. It is managed in ICU - IV medications instead of oral - IV Vasodilator, calcium channel blocker or beta blocker can be given

Question 36

Having hypertension puts you at increased risk for which conditions?

Answer 36

- Stroke - Ischaemic Heart Disease - Heart Failure - Chronic Kidney Disease - Cognitive Decline - Premature Death

Question 37

For every 2 mmHg rise in blood pressure, what happens?

Answer 37

- The risk of IHD increases by 7% | - The risk of stroke increases by 10%

Question 38

If you get newly diagnosed with hypertension, what follow up tests should you get?

Answer 38

- Urine albumin:creatinine ratio for proteinuria and dipstick for microscopic haematuria to assess for kidney damage - Bloods for HbA1c, renal function and lipids - Fundus examination for hypertensive retinopathy - ECG for cardiac abnormalities

Question 39

What is involved in the initial management of someone with hypertension?

Answer 39

- Establish a diagnosis - Investigate for possible causes and end organ damage - Advice on lifestyle. This includes recommending a healthy diet, stopping smoking, reducing alcohol, caffeine and salt intake and taking regular exercise.

Question 40

What is involved in conservative management of hypertension?

Answer 40

- Recommend a healthy diet - Stop smoking - Reducing alcohol intake - Reducing caffeine intake - Reducing salt intake - Regular exercise

Question 41

What is involved in the medical management of hypertension? Hint: just a broad overview of drugs used

Answer 41

Remember it with ABCD ARB ``` A - Ace Inhibitors B - Beta Blockers C- Calcium Channel Blockers D- Thiazide-like Diuretics ARB - Angiotensin II receptor blocker ```

Question 42

When are angiotensin II blockers used for hypertension?

Answer 42

Angiotensin receptor blockers are used in place of an ACE inhibitor if the person does not tolerate ACE inhibitors (commonly due to a dry cough) or the patient is black of African or African-Caribbean descent.

Question 43

Which 2 anti-hypertensive drugs should not be used toghether?

Answer 43

ACE inhibitors and Angiotensin II receptor blockers

Question 44

Who is medical management offered to for hypertension?

Answer 44

- All patients with stage 2 or 3 hypertension - All patients under 80 with stage 1 hypertension that also have a Q-risk score of 10% or more, diabetes, renal disease, cardiovascular disease or end organ damage.

Question 45

Who is medical management not offered to for hypertension?

Answer 45

Anyone with stage 1 hypertension either - over the age of 80 - under 80, but with a Qrisk3 score less than 10% and no evidence of diabetes, renal disease, cardiovascular disease or end organ damage

Question 46

What is involved in step 1 in the pathway of prescribing anti-hypertensive medications?

Answer 46

- If aged less than 55 and non-black, use an Ace Inhibitor | - If aged over 55, or black of African or African-Caribbean descent, use a Calcium channel blocker

Question 47

What is involved in step 2 in the pathway of prescribing anti-hypertensive medications?

Answer 47

- If aged less than 55 and non-black, use 'A' + 'C or D' | - If aged over 55, or black of African or African-Caribbean descent, use 'ARB' + 'C or D'

Question 48

What is involved in step 3 in the pathway of prescribing anti-hypertensive medications?

Answer 48

- If aged less than 55 and non-black, use 'A' + 'C' + 'D' | - If aged over 55, or black of African or African-Caribbean descent, use 'ARB' + 'C' + 'D'

Question 49

What is involved in step 4 in the pathway of prescribing anti-hypertensive medications?

Answer 49

A/ARB + C + D then a final drug depending on serum potassium levels. - If equal to 4.5mmol/L or less, use potassium sparring diuetic such as sporonolactone - If its more than 4.5mmol/L, use an alpha or beta blocker

Question 50

What should you do if BP remains unctronlled even after treatment at stage 4?

Answer 50

Seek specialist advice

Question 51

How does Spironolactone work? Why are they helpful?

Answer 51

Spironolactone is a “potassium-sparing diuretic” that works by blocking the action of aldosterone in the kidneys, resulting in sodium excretion and potassium reabsorption. This can be helpful when thiazide diuretics are causing hypokalemia.

Question 52

Which anti-hypertensive drugs do you need regular U&Es monitoring for? Why?

Answer 52

ACE Inhibitors and all diuretics (thiazide-like + spirinolactone). - Spirinolactone can cause hyperkalaemia - ACE inhibitors can cause hyperkalaemia - Thiazide-like diuretics can cause electroyle disturbances

Question 53

If treating someone over the age of 80 on antihypertensives, what BP are you aiming for?

Answer 53

Systolic under 150 | Diastolic under 90

Question 54

If treating someone under the age of 80 on antihypertensives, what BP are you aiming for?

Answer 54

Systolic under 140 | Diastolic under 90